Chronic femoral arteriovenous fistula masquerading as the postphlebitic syndrome.

A patient with a traumatic femoral arteriovenous fistula was misdiagnosed for 11 years as having "postphlebitic syndrome." Angiography revealed diffuse dilatation of the veins and arteries of the right lower extremity with the iliac vein measuring 16.0 cm in diameter and the cava 6.0 cm in diameter. Operative repair of the fistula has resulted in marked clinical improvement and return of the patient to fulltime employment. A history of trauma should be sought when a patient presents with unilateral chronic venous insufficiency.

Surgical treatment of chronic mesenteric arterial insufficiency.

The treatment of 41 patients with chronic mesenteric insufficiency is reviewed: 20 men and 21 women with a mean age of 59 years were treated and observed for an average of 42 months. Thirty-one patients had symptoms of intestinal angina whereas 10 patients underwent prophylactic revascularization during other aortic operations. All but one patient had revascularization of the superior mesenteric artery, alone or in combination with another revascularization. Various surgical techniques were used, including retrograde bypass in 24 patients, antegrade bypass in 11 patients, and endarterectomy in the remaining six patients. Seven patients had acute abdominal symptoms and required emergency operation while in the hospital awaiting elective revascularization. There were two deaths in the perioperative period (4.9%), both caused by bowel necrosis. Six patients are known to have had late revascularization failure, resulting in recurrent symptoms in three patients and two subsequent deaths. All patients who remained asymptomatic after late graft failure had undergone multiple vessel revascularization; no patient revascularized prophylactically had symptoms of intestinal angina during the follow-up period. Early mesenteric revascularization is a safe and effective method of relieving the symptoms of chronic visceral ischemia and may prevent the development of fatal bowel necrosis.

Mycotic abdominal aortic aneurysm induced by immunotherapy with bacille Calmette-Guérin vaccine for malignancy.

Successful surgical treatment of a mycotic abdominal aortic aneurysm infected with Mycobacterium bovis is described. The infecting organism can be traced to an intraneoplastic injection of bacille Calmette-Guérin (BCG) vaccine into a cutaneous malignant melanoma nodule 14 months before aneurysm detection (17 months before operation). Treatment consisted of aneurysm excision, in situ prosthetic graft placement, and antituberculous medications. This patient represents the first reported case of BCG-induced mycotic aortic aneurysm.

Infected aortobifemoral prosthesis--a dreaded complication.

From 1980 to 1985 13 patients were identified with infected aortofemoral grafts. Potential predisposing factors identified included a history of multiple femoral arterial procedures (10 patients; 77%) as well as perioperative infections occurring at the time of a prior femoral operation (five patients; 38%). Patients presented with suppurative groin infections (11) or ruptured pseudoaneurysms (2). Two who had previously undergone bilateral amputations were managed by removal of their aortic grafts without revascularization. Eleven other patients were managed by excision of the entire prosthesis (6 aortic grafts), partial graft excision (five graft limbs) or local treatment alone (three graft limbs). Revascularization through uninfected tissue planes was performed on 14 limbs with salvage of 11 (limb salvage 79%); whereas three limbs not revascularized required major amputation (limb salvage 0%). Despite an aggressive surgical approach five patients (38%) required a major amputation and there were three deaths (23% mortality). Once the diagnosis of an infected graft is made, early graft excision and prompt revascularization are encouraged.

Descending thoracic aortofemoral-femoral bypass: a remedial alternative for the failed aortobifemoral bypass.

The patient with densely scarred retroperitoneum, multiple previous celiotomies, failed remedial retroperitoneal aortobifemoral graft or multiple extra-anatomic graft failures presenting with limb-threatening ischemia taxes the ingenuity of the most experienced vascular surgeon. Lower extremity revascularization, in these situations, is dependent upon achieving adequate femoral arterial inflow. One remedial alternative method to achieve this goal is the descending thoracic aortofemoral-femoral bypass (DTAF-F). The authors' experience with three recent patients requiring DTAF-F is described, and literature of similar alternative techniques is reviewed.

Femoral anastomotic aneurysms: a continuing challenge.

The methods used in management of 102 femoral anastomotic aneurysms (FAAs) were analyzed, and a case control study was performed in an effort to define potential etiologic factors. Most FAAs resulted from host vessel degeneration, although broken sutures, infection, and prosthetic graft dilatation contributed in some cases. Patients forming FAAs after aortofemoral bypass more often were hypertensive, had progression of distal disease, and showed diffuse atherosclerosis when compared with control patients. The use of braided synthetic sutures, woven Dacron grafts, and concomitant femoral endarterectomy correlated with FAA development, whereas diabetes mellitus, multiple femoral operations, local wound-healing problems, and occlusion of the superficial femoral artery did not correlate with the formation of FAAs. Ninety FAAs (88%) were treated surgically with an operative mortality rate of 3%. The most common surgical technique was aneurysmectomy with interposition prosthetic graft replacement. Durability of the repair was better if a simultaneous outflow procedure was performed and if the reconstruction was done before complications developed. Complicated FAAs are still responsible for significant morbidity and loss of life despite aggressive surgical management. Elective FAA repair is the preferred method of treatment.

Nonoperative management of selected popliteal aneurysms.

In the management of 95 popliteal aneurysms, surgical therapy was initially successful in 90% of operations, while major limb amputation was required in 6%. Durability of surgical reconstruction was improved if autogenous saphenous vein was used and if the reconstruction was performed before development of complications. Twenty asymptomatic popliteal aneurysms were repaired without loss of limb and with a five-year secondary cumulative patency rate of 93%. Among 26 small asymptomatic popliteal aneurysms managed without operation, complications developed in only two (8%) during the period of observation. Because of the demonstrated safety and efficacy of surgical treatment, repair of popliteal aneurysms is recommended in acceptable operative candidates. However, there exists a subgroup of asymptomatic higher-risk patients with small popliteal aneurysms in whom a conservative nonoperative approach is reasonably safe.

The carotid sinus syndrome: a frequently overlooked cause of syncope in the elderly.

Exaggerated carotid sinus reflexes may account for alterations in consciousness responsible for significant disability and injury in elderly patients. Nonspecificity of symptoms and concomitant medical conditions frequently delay diagnosis and therapy. During a recent 9-year period, 82 patients were identified as having symptomatic carotid sinus hypersensitivity (CSH). Fifty-nine patients described complete syncope, 73 patients had multiple syncopal or near-syncopal episodes, and 40 patients related cervical pressure or motion as provocative events. Electrophysiologic testing demonstrated that 47% had cardioinhibitory CSH, 26% had vasodepressor CSH, and 27% had combined vasodepressor and cardioinhibitory CSH. The mean follow-up period of all patients was 36 months. Surgical therapy included ventricular demand pacemaker implantation in 33 patients and carotid sinus denervation in seven patients. Medical therapy was used in 32 patients, 11 mildly symptomatic patients were not treated, and 3 patients had carotid sinus irradiation. Pacemaker implantation relieved symptoms in 53%; however, 11 patients (33%) had significant postoperative complications. Carotid sinus denervation relieved symptoms in 86%, medical therapy in 54%, and carotid sinus irradiation in 33% of patients. Because of its demonstrated effectiveness in all variants of CSH and negligible perioperative morbidity, carotid sinus denervation should be offered to acceptable operative candidates when the diagnosis of CSH is confirmed.